Nursing Elites

1. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention?

• A. Pallor
• B. Increased temperature
• C. Dyspnea
• D. Involuntary muscle spasms

Correct answer: C

Rationale: Dyspnea indicates a potential complication such as pneumothorax or incorrect catheter placement, requiring immediate attention. Pallor may indicate anemia but is not as urgent as dyspnea in this context. Increased temperature could be a sign of infection but is not as critical as respiratory distress. Involuntary muscle spasms are not directly related to central venous catheter placement and are of lower priority compared to respiratory issues.

2. Which statement best describes the effects of immobility in children?

• A. Immobility prevents the progression of language and fine motor development
• B. Immobility in children has similar physical effects to those found in adults
• C. Children are more susceptible to the effects of immobility than adults are
• D. Children are likely to have prolonged immobility with subsequent complications

Correct answer: B

Rationale: The correct answer is B. Immobility in children indeed has physical effects similar to those found in adults. However, it can also significantly impact their development and growth. Choice A is incorrect because immobility does not solely prevent language and fine motor development but affects various aspects. Choice C is incorrect as susceptibility to the effects of immobility may vary between children and adults depending on individual factors. Choice D is incorrect as not all children are likely to have prolonged immobility with subsequent complications.

3. The nurse is caring for a 7-year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?

• A. Decreased carbohydrates and fat
• B. Decreased sodium and potassium
• C. Increased potassium and protein
• D. Increased sodium and fluids

Correct answer: B

Rationale: The correct answer is 'Decreased sodium and potassium.' In acute glomerulonephritis, managing edema and oliguria is crucial. Reducing sodium and potassium intake helps achieve this by decreasing fluid retention and workload on the kidneys. Choice A, 'Decreased carbohydrates and fat,' is not directly related to managing AGN. Choice C, 'Increased potassium and protein,' is incorrect as increasing potassium can be harmful in kidney conditions. Choice D, 'Increased sodium and fluids,' is also incorrect as it can exacerbate edema and hypertension in AGN.

4. What is the most effective nursing intervention to prevent atelectasis from developing in a postoperative client?

• A. Maintain adequate hydration
• B. Assist the client to turn, deep breathe, and cough
• C. Ambulate the client within 12 hours
• D. Splint the incision

Correct answer: B

Rationale: The correct answer is to assist the client to turn, deep breathe, and cough. This intervention helps to expand the lungs and prevent atelectasis in postoperative clients. Maintaining adequate hydration is important for overall health but is not the most effective intervention for preventing atelectasis. Ambulating the client within 12 hours is beneficial for preventing complications after surgery, but it may not be as directly effective in preventing atelectasis as turning, deep breathing, and coughing. Splinting the incision is important for postoperative care, but it does not specifically address the prevention of atelectasis.

5. A nurse is collecting data from a client who has hypocalcemia. Which of the following findings should the nurse expect?

• A. Decreased deep-tendon reflexes
• B. Skeletal muscle weakness
• C. Hypoactive bowel sounds
• D. Tingling of the lips

Correct answer: D

Rationale: The correct answer is D, tingling of the lips (perioral tingling). This is a common symptom of hypocalcemia due to increased neuromuscular excitability. Choice A, decreased deep-tendon reflexes, is more indicative of hypercalcemia. Choice B, skeletal muscle weakness, is associated with hypokalemia. Choice C, hypoactive bowel sounds, is not a typical finding in hypocalcemia.

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